The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up

Native anterior cruciate ligament obliquity versus anterior cruciate ligament graft obliquity: an observational study using navigated measurements

BACKGROUND

The goal of anterior cruciate ligament reconstruction is to attain a graft that closely resembles the native anterior cruciate ligament anatomy. By reconstructing the original anatomy, one hopes to eliminate issues related to graft elongation, impingement, and excessive tension while achieving ideal knee kinematics.

HYPOTHESIS

Clinical grafts placed using the transtibial technique will differ in the sagittal and coronal planes when compared with obliquity of the anatomic anterior cruciate ligament.

STUDY DESIGN

Controlled laboratory study/case series; Level of evidence, 4.

METHODS

With the assistance of computer navigation, our study compared the anterior cruciate ligament orientation of 5 cadaver knees with 12 clinical anterior cruciate ligament-reconstructed knees using the transtibial technique.

RESULTS

Clinical graft obliquity differed from the anatomic anterior cruciate ligament in all flexion angles: 0 degrees, 30 degrees, 60 degrees, and 90 degrees. In the sagittal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 13.6 degrees, 12.7 degrees, 16.7 degrees, and 17 degrees, respectively. In the coronal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 4.9 degrees, 7.6 degrees, 8.9 degrees, and 12.7 degrees, respectively. Paired t tests demonstrated that the difference between the clinical and anatomic anterior cruciate ligament was significant (P <.05), except in the coronal plane at 0 degrees of flexion. In spite of this, all patients demonstrated a negative pivot shift and Lachman at the conclusion of their reconstructions and at 6-month follow-up.

CONCLUSION

The sagittal and coronal plane obliquity of well-functioning grafts placed using the transtibial technique were more vertical than anatomic fibers.

CLINICAL RELEVANCE

Graft obliquity, in both the coronal and sagittal plane, may be an important means to target appropriate anterior cruciate ligament graft position and can be monitored using surgical navigation systems.

Relevant traumatic injury of the knee joint-MRI follow-up after 7-10 years

OBJECTIVE

To evaluate prospectively the history of relevant traumatic knee injuries at least 7 years after trauma by MRI focusing on the development of degenerative changes.

MATERIALS AND METHODS

Seventeen patients without baseline degenerative changes had a follow-up knee MRI several years after relevant knee injury (interval baseline-follow-up was 9.1 years, S.D. +/-1.3 years). Relevant knee injury was defined as complete cruciate or collateral ligament rupture, traumatic meniscal tear or osteochondral injury. Baseline MRI examinations were evaluated for traumatic ligamentous, chondral, meniscal and osseous lesions. Follow-up MRIs were evaluated for ligamentous and meniscal status, articular surface and incidence of degenerative changes such as cartilage loss, osteophytes and bone marrow lesions.

RESULTS

Among the 11 patients who had a complete rupture of the ACL at baseline, 3 (27.3%) presented with cartilage loss. Among the eight patients who had suffered a post-traumatic meniscal tear at baseline, four (50%) presented with cartilage loss at follow-up. Among the five patients who had an osteochondral fracture at baseline, two (40%) presented with cartilage loss at follow-up imaging. Cartilage loss in all cases was observed adjacent to the subregions where meniscal damage and/or osteochondral incongruence was/were present at follow-up imaging.

CONCLUSION

We hypothesize that the post-traumatic or postsurgical meniscal damage and the persistence of an irregular articular surface may have played a role in the subsequent loss of cartilage in our patient population.

Comparative study of knee anterior cruciate ligament reconstruction with or without fluoroscopic assistance: a prospective study of 73 cases

INTRODUCTION

Correct placement of both tibial and femoral tunnels is one of the main factors for a favorable clinical outcome after anterior cruciate ligament (ACL) reconstruction. We used an original system of computer assisted surgery (CAS). The system, based on fluoroscopic guidance combined with special graphical software of image analyzing, showed to the surgeon, before drilling, the recommended placement of tibial and femoral tunnel centers. We compared the first anatomical and clinical results of this procedure to the usual one single incision technique.

MATERIALS AND METHODS

We conducted a prospective study on 73 patients; 37 patients were operated on with CAS and 36 without CAS, by the same senior surgeon. The mean age was 27 years for both groups. Every patient was reviewed at an average of 2.2 years (range 1-4.5) by an independent observer, using IKDC scoring system, KT-1000, and passive stress radiographs.

RESULTS

Time between ACL rupture and reconstruction averaged 30 months for both groups. CAS needed 9.3 min extra surgery time. Clinical evaluation was graded from A to C as per the IKDC scoring system: 67.6% A, 29.7% B, 2.7% C with CAS; and 60% A, 37.1% B, 2.9% C without CAS. IKDC subjective knee evaluation score averaged 89.7 with CAS and 89.5 without CAS. Pre operative KT-1000 maxi manual differential laxity averaged 7. At revision time, all the patients after CAS had a differential laxity less than 2 and 97.7% without CAS. Stress X-rays differential laxity averaged 2.4 mm with CAS and 3 mm without CAS. The area of dispersion of the tunnels' center was smaller on the femoral side using the CAS method. There was no statistically significant difference between both groups using IKDC score, KT-1000 and passive stress radiographs.

CONCLUSIONS

The CAS method provided a more accurate and reproducible tunnels placement without clinical significant effect.

Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment

ACL-reconstruction aims to restore joint stability and prevent osteoarthritis; however, malfunction and osteoarthritis are often the sequelae. Our study asks whether ACL-reconstruction or conservative treatment lead to better long-term results. In this retrospective cohort study, 136 patients with isolated ACL-rupture who had been treated by bone-ligament-bone transplant or conservatively were identified. Twenty-seven of these were excluded because of a revision operation in the 11.1 years follow-up period, leaving 109 patients (60 reconstructions and 49 conservatively treated) for evaluation based on clinical, radiological and internationally accepted knee-scores (Tegner, IKDC, Kellgren and Lawrence). An individual cohort study is classified as EBM level 2b according to the Oxford Centre of EBM. We observed significantly better knee-stability (P = 0.008) but more osteoarthritis (Grade II or higher) after ACL-reconstruction (42% vs. 25%). Physical activity levels were similar in both groups during the follow-up period (P = 0.16). Eleven years after ACL-rupture the physical activity levels are similar for both groups. After ACL-reconstruction, stability is higher as is osteoarthritis, whereby the result is not necessarily perceived as better subjectively. Specifically, this retrospective study yielded a 24% incidence of oseoarthrits 11 years after conservative management of ACL-rupture in patients not needing secondary surgery. The risk of secondary meniscal tears is reduced after ACL reconstruction, which reduces the negative effects of OA after surgery. The ultimate objective would be to achieve a good subjective outcome by conservative treatment followed by a rehabilitation program designed to keep secondary meniscus tears at a low level.

Meniscal allografts: indications and outcomes

Meniscal allograft transplantation was introduced into clinical practice now over 20 years ago for the treatment of the symptomatic postmeniscectomy patient who has not yet developed osteoarthritis. Over the years, the indications have been fine-tuned and certain risk factors for failure have been identified. As the number of publications increases steadily, we now know that meniscal allografting significantly reduces pain and improves function. Recent data also suggest a potential chondroprotective effect in a subpopulation of patients. However, the major drawback in all meniscus allograft studies is the general lack of a control population. To improve our knowledge, future prospective studies should include objective outcome tools to evaluate the status of the allograft in addition to the clinical scoring systems. Future research should focus to elucidate the biologic and cellular processes involved in graft repopulation and remodelation.